Authors: Dr. D. William Molloy and Dr. Roger Clarnette
Before setting up, raters ensure that subjects have hearing and vision aids to maximize communication. Hearing is tested by asking "What is your name?" Subjects are advised that they will be asked some questions; "Would it be all right to ask you some questions about your memory?". Raters should have their props ready (pencil and paper). Raters also need a clock to measure time. Laminated cards are provided, printed with "CLOSE YOUR EYES" and the two five-sided figures to standardize these parts of the test.
The rater introduces the test by saying, "I am going to ask you some questions and give you some problems to solve. Please try to answer as best you can." The SMMSE provides exact verbatim instructions to administer each item in the test. Raters should ask questions exactly as they appear in the SMMSE.
Raters are trained to score responses. Some tasks are easier than others. For example, when one reads the statement "Close your eyes", if subjects close their eyes, they score a point. If they do not, they lose a point. Other parts of the test are not so easy. Scoring the spelling of "World" backwards can be problematic given the permutations and combinations of potential responses. Explicit instructions are provided to score this task. Basically, superimpose the answers on the correct template and score the number of letters occurring in the correct order to give the subject the maximum number of points.
Problems can arise in scoring the orientation to place. For example country, province/state/county, city/town, building and floor are asked in order of size from the largest geo-political unit to the smallest. Decide in advance what will be accepted as correct answers. In general, use the local terms people use to describe their location. In some cases, if county is more important than state, then this is used.
The name of the building may be problematic. We work in the Henderson site of the Hamilton Civic hospitals, called after Nora Franc is Henderson who helped found it. We merged with the Chedoke-McMaster hospitals and are now known as the Hamilton Health Sciences Corporation. We score a correct point for any of these because this is so confusing. We work on the ground floor, if you come in one entrance. We are in the basement if you come in another. We accept basement, ground or main floor. In the community, the instructions and scoring can be modified to ask "What street is this?" and "What room is this?" or "What number is this house?".
We have provided time limits for each answer. Raters begin to time from the end of the instruction. Subjects are not told they are being timed and this is measured inconspicuously to avoid added pressure. If the subject takes longer than the allotted time, the rater says "Thank you, that was fine" and proceeds to the next question. If the subject is trying hard to complete a task, for example, the five sided figures and goes over time, the rater does not interrupt until the person is finished and scores the task at the one minute mark. The subject will not score the point if it was not completed during the allotted time period. If subjects give more than one answer, score the last answer only.
The props are a potential source of variability in the administration and scoring. If it is left to the rater to write out "Close Your Eyes" or to draw the two five-sided figures, they can be hand written on the spur of the moment on scraps of paper. The quality of the example can vary widely. The SMMSE provides the instruction "Close Your Eyes" and the two five-sided figures on opposite sides of a laminated card. They are in large plain font, clearly written and easy to read.
The MMSE originally offered three words "Apple," "Table," and "Penny" to test registration and recall. In some cases, where subjects were tested repeatedly, as soon as the rater said "I am going to name three objects and I want you to repeat them back to me," even before they said the words, the subject offered "Apple, Table, Penny." It became obvious that we needed alternate forms of these three words. We created alternate three-word sets with the same word frequency e.g., "Ball, Car, Man" and "Bull, War, Pan". The rater slowly names the three objects to test the subject’s ability to register this new information. The rater may not repeat the words, so it is important to say them clearly and control for distractions during this task. The subject is given 20 seconds to repeat them. One point is given for each word correctly recalled after the first administration. The order of recall is not important. After the subject has recalled as many as he or she can, the rater scores the number of correct items recalled.
If the subject has not repeated (registered) the three words, the rater can then help the subject to register the three items for the delayed recall task. The rater says the words at one second intervals and then asks the subject to repeat the words until all three are repeated. The rater can repeat until they are learned, to a maximum of five times. The subject is then advised that he or she will be asked to recall them later. "Remember these words because I am going to ask you to name them later."
In this task the subject is asked to spell "World". After successfully spelling it, he or she is asked to spell it backwards. The number of letters in the correct (reverse) order is the score. A simple method of scoring this task and a list of possible answers and examples is provided.
The serial sevens task is presented as an alternative to spelling "World" backwards. The two tasks are not equivalent. The serial sevens is an easier task, and the scoring is easier. It can be used as an alternate to spelling "WORLD" backwards in people who are illiterate.
Subjects are asked to name a watch and pencil. Use a traditional wooden pencil with an eraser on the end. Use a watch with traditional face. "Clock" or "time" are not accepted. Ten seconds are allowed for each.
Subjects are asked to repeat this phrase. Subjects have ten seconds to respond and must say the phrase verbatim. Raters should enunciate the phrase clearly, because subjects with high frequency hearing loss (presbycusis) may not hear the sibilants and will repeat "No if, and or but". This is a clue that there is high frequency hearing loss and these subjects should have their hearing assessed.
The subject is given the pencil and paper and asked to write a complete sentence. Thirty seconds are given and the sentence must have a subject, verb and object. Spelling mistakes are ignored.
Give the subject the pencil, with the eraser, and a clean piece of paper. Examples are provided to score this task. Many older adults draw shaky, wiggly lines with unclear angles that are more curved than straight. These are acceptable, as long as the person has two five-sided figures intersecting to form a four-sided figure.
The rater holds up a piece of paper and says "Take this piece of paper in your (non-dominant) hand, fold the paper in half once with both hands and put it down on the floor". Thirty seconds are allowed and one point is given for each step properly executed. The nondominant hand is used because people will automatically take objects with their dominant hand. This test is given at the end so the rater can observe the hand that the person used to write in the previous task. If the subject uses the right hand say "Take this piece of paper in your left hand" and vice versa. When you give the instructions, hold the piece of paper out in front of the person, out of reach, and do not allow the person to take the paper until you have given the three instructions. Hold the paper in the subject’s midline and push it forward when you have given the instructions, not before.
After each task we recommend using an encouraging remark such as, "Well done! That was very good. Now, if you don’t mind, I would like you to".
If the subject asks "How was that?", we usually respond with "Very good". If the subject asks "Are we finished now?" we reply "Almost. You are doing very well. If you don’t mind, I would like you to".